Child Health Update Pacifier use in the first month of life

Child Health Update
Pacifier use in the first month of life
Ran D. Goldman
MD FRCPC
Abstract
Question As a family physician who frequently attends deliveries and follows up with neonates, parents often
ask me if they can provide their newborns with pacifiers in order to calm infants down, reduce crying, and
improve sleep. Is pacifier use safe in the first month of life?
Answer While pacifiers are useful for soothing, there is concern that their use might cause early weaning of
breastfeeding owing to “nipple confusion.” Several organizations, such as the World Health Organization and the
United Nations Children’s Fund, recommend avoiding use of pacifiers in term infants who breastfeed. However,
evidence suggests that it might not be pacifier use that causes premature cessation of breastfeeding, and that use
of pacifiers might only be a sign of a maternal decision to stop breastfeeding.
La suce durant les premiers mois de vie
Résumé
Question En tant que médecin de famille qui procède souvent à des accouchements et qui fait le suivi des
nouveau-nés, les parents me demandent souvent s’ils peuvent donner une suce à leur bébé pour le calmer,
atténuer ses pleurs et améliorer son sommeil. L’utilisation de la suce est-elle sécuritaire durant les premiers mois
de vie?
Réponse Bien que les suces soient utiles pour apaiser, on s’inquiète que leur usage puisse causer un sevrage
précoce de l’allaitement en raison de la «confusion de mamelons». Plusieurs organisations, dont l’Organisation
mondiale de la Santé et le Fonds des Nations Unies pour l’enfance, recommandent d’éviter l’utilisation des
suces chez les enfants nés à terme et allaités au sein. Par contre, des données probantes portent à croire que
l’utilisation de la suce pourrait ne pas être la cause d’un arrêt prématuré de l’allaitement maternel et le recours à
la suce pourrait n’être qu’un signe de la décision de la mère d’arrêter l’allaitement au sein.
B
reastfeeding has been promoted heavily in recent
decades as the sole means of nutrition for infants
up to 6 months of age. The Canadian Paediatric Society1
and the American Academy of Pediatrics2 recommend
exclusive breastfeeding for the first 6 months of life for
healthy, term infants, recognizing breast milk as the
optimal food for infants. After that period, additional
food should be introduced, and breastfeeding can be
continued as a complementary source of food.
Infants have a strong sucking reflex that helps with
breastfeeding. The process of sucking was also found
to be helpful in calming and soothing babies. In one
Canadian study, more than 80% of parents used pacifiers
for their babies.3 However, in recent years a potential
“nipple confusion” between breast, bottle, and pacifier
was suspected.
Should parents avoid pacifiers?
One Canadian study found that pacifier use was possibly a marker of breastfeeding difficulties or a potential
lack of motivation to breastfeed among mothers rather
than a true cause of early weaning.3 In this randomized trial in Montreal, Que, 140 mothers were asked to
avoid pacifier use (experimental group) and were compared with a similar group that was not asked to restrict
use (control group). The experimental group avoided
pacifier use more often (38.6% vs 16.0% in the control
group) and reduced infants’ daily use of pacifiers (40.8%
vs 55.7% in the control group); however, similar rates of
early weaning were reported (18.9% in the experimental group vs 18.3% in the control group in the intentionto-treat analysis). Interestingly, in a separate analysis
based on treatment given (ignoring randomization), an
association was found between daily exposure to pacifiers and weaning by 3 months of age (25.0% of the
exposed group vs 12.9% of the unexposed group).3
Owing to the possibility of premature weaning, the BabyFriendly Hospital Initiative of the World Health Organization
and United Nations Children’s Fund recommends avoiding
pacifier use in term infants who breastfeed.4
A 2011 Cochrane review5 looked at randomized and
quasi-randomized controlled trials investigating the
Recent evidence—more confusion
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Child Health Update
effects of pacifiers in healthy, breastfeeding, full-term newborns. In
2 trials with almost 1300 newborns, pacifier use had no significant
effect on the proportion of infants exclusively breastfed at 3 months
of age (risk ratio [RR] 1.00; 95% CI 0.95 to 1.06) and at 4 months of
age (RR 0.99; 95% CI 0.92 to 1.06). Similarly, there was no effect on
partial breastfeeding at 3 months of age (RR 1.00; 95% CI 0.97 to
1.02) and at 4 months of age (RR 1.01; 95% CI 0.98 to 1.03). However,
Jaafar et al cautioned that short-term breastfeeding difficulties faced
by mothers and the long-term effects of pacifier use on infants’ health
were not investigated.
Most recently, a retrospective before-and-after study attempting to
determine the association between removing routine distribution of
pacifiers in a mother-baby unit and breastfeeding initiation was conducted in Oregon.6 Restricting pacifiers (while not restricting access to
formula) actually decreased exclusive breastfeeding, increased supplemental formula feeding, and increased exclusive formula feeding.
The issue of pacifier use is still under some debate. While awaiting more definitive studies, the Pediatric Research in Emergency
Therapeutics program recommends following current guidelines:
avoid pacifier use in the first month of life for healthy, breastfeeding newborns. Competing interests
None declared
Correspondence
Dr Ran D. Goldman, BC Children’s Hospital, Department of Pediatrics, Room K4-226, Ambulatory
Care Bldg, 4480 Oak St, Vancouver, BC V6H 3V4; telephone 604 875-2345, extension 7333; fax 604
875-2414; e-mail [email protected]
References
1. Blonde M. Nutrition for healthy term infants: recommendations for birth to six months. Ottawa, ON:
Canadian Paediatric Society; 2013. Available from: www.cps.ca/documents/position/nutrition-healthy-term-infants. Accessed 2013 Mar 24.
2. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human
milk. Pediatrics 2012;129(3):e827-41. Epub 2012 Feb 27.
3. Kramer MS, Barr RG, Dagenais S, Yang H, Jones P, Ciofani L, et al. Pacifier use, early weaning,
and cry/fuss behavior: a randomized controlled trial. JAMA 2001;286(3):322-6.
4. United Nations Children’s Fund [website]. The Baby-Friendly Hospital Initiative. New York, NY:
United Nations Children’s Fund; 2013. Available from: www.unicef.org/programme/breastfeeding/baby.htm. Accessed 2013 Mar 24.
5. Jaafar SH, Jahanfar S, Angolkar M, Ho JJ. Pacifier use versus no pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database Syst Rev
2011;(3):CD007202.
6. Kair LR, Kenron D, Etheredge K, Jaffe AC, Phillipi CA. Pacifier restriction and exclusive breastfeeding. Pediatrics 2013;131(4):e1101-7. Epub 2013 Mar 18.
Child Health Update is produced by the Pediatric Research in
Emergency Therapeutics (PRETx) program (www.pretx.org) at
the BC Children’s Hospital in Vancouver, BC. Dr Goldman is
Director of the PRETx program. The mission of the PRETx program is to promote child health through
evidence-based research in therapeutics in pediatric emergency medicine.
Do you have questions about the effects of drugs, chemicals, radiation, or infections in children?
We invite you to submit them to the PRETx program by fax at 604 875–2414; they will be addressed
in future Child Health Updates. Published Child Health Updates are available on the Canadian
Family Physician website (www.cfp.ca).
Pediatric Research in Emergency Therapeutics
500 Canadian Family Physician • Le Médecin de famille canadien
| Vol 59: MAY • MAI 2013